Common Culture – A source of strength for integrated delivery systems 

By Cathy Eddy, Health Plan Alliance, July 25, 2016

On July 20, I had the opportunity to be part of a discussion that American Hospital Association and Sharp Healthcare hosted in San Diego for integrated delivery systems with health plans. I was asked to facilitate an exchange on key trends in product innovation.

During the day the discussion hit on many of the national trends we are seeing in our work with health plans around the country:

  • Strategic Value
  • Growth
  • Changes in Ownership
  • Alignment and Intersection
  • Government Oversight

During my session, we went into depth about the need for alignment between payers and providers and the key intersection points where health systems and their provider-sponsored health plans need to work in tandem to be successful. These areas are:

  • Governance
  • Customer experience
  • Contracting strategy
  • Risk adjustment
  • Quality metrics
  • Clinical integration
  • Informatics and analytics
  • Technology assessment and IT infrastructure

Jim Hinton, President & CEO, Presbyterian Healthcare Services who chaired the meeting, suggested I add a slide about Culture, another area that is a key to success. He shared that his team will call out when the word “side” is mentioned. I’ve been on the Presbyterian Health Plan board for 10 years and the organization does a great job of looking at its challenges and opportunities from a system point of view. We have an annual planning retreat with the system and health plan boards that contribute to a common culture at the governance level.  Jim’s comment reminded us that words matter.  So does culture.

Mike Murphy, CEO of Sharp Healthcare, led a discussion with a team of his executives including Melissa Hayden Cook, the CEO of Sharp Health Plan. They did a great overview about how they work as an integrated health system. This organization has built the “Sharp Experience” that drives a common culture. For the past 15 years, Sharp has held annual all-employee meetings  – three sessions where 17,000 employees, 2,600 physicians and 2,000 volunteers are invited to take a bus trip to the convention center and recommit to Sharp Healthcare and their role with the system. Their vision: To be the best health care system in the universe!

Integrated Delivery Systems often include several business models and that can result in different cultures. The language of a health plan is different than the one used by providers. The meaning given to the same words can be different – for instance, revenue. In a health plan, revenue comes from premium dollars, but payers see provider revenue as a cost. Roles can have the same title, but different responsibilities  -- care manager is just one example. It is a challenge for our integrated delivery systems to develop a common culture.  Kudos to Sharp and Presbyterian for the work they have done in this arena.

Value-based payments will drive the need for collaboration. Population health focuses on the care continuum. The customer experience is often a reflection of the system’s culture…positive when everyone is working with a common set of values and negative when the hand-offs are confusing and disjointed. As we strive to successfully integrate providers and payers, the value of a common culture can be an important key to success.

So how healthy is your culture? Listen carefully to see the words that are a part of conversations in your health system to see if you are thinking like an integrated system.

This post originally apperared on the Health Plan Alliance Blog on June 28th, 2016. You can see the original at and see all the Health Plan Alliance Blog posts at


Connecting individuals to complex health care fraud schemes

By Claire Thayer, July 25, 2016

The U.S. Department of Justice has been busy in tracking down and convicting criminals in health care fraud related crimes.  This week, the U.S. Department of Justice announced its largest criminal healthcare fraud case against individuals in $1billion Medicare fraud scheme. This follows U.S. Department of Justice news on June 22, 2016, of an unprecedented nationwide sweep led by the Medicare Fraud Strike Force in 36 federal districts, resulting in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings.  In addition, the HHS Centers for Medicare & Medicaid Services (CMS) is suspending payment to a number of providers using its suspension authority provided in the Affordable Care Act.  This coordinated takedown is the largest in history, both in terms of the number of defendants charged and loss amount. 

An OIG report published earlier this year found that in FY 2015, FBI efforts resulted in over 625 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 144 health care fraud enterprises.  These and other findings are the focus of a recent MCOL infographoid, co-sponsored by LexisNexis Health Care, highlighted below:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.


What Pokémon Go Means for Health Care

By Kim Bellard, July 21, 2016

In recent days there have been a flood of stories trying to explain the Pokémon Go craze.  
Many -- e.g., The New York Times and Fast Company -- believe that Pokémon Go is finally going to make augmented reality mainstream, as well as showing AR's advantages over virtual reality, since the latter typically requires at least a headset plus a high powered PC.  It makes AR quick, easy, and free, teaching players how AR can seamlessly fit into the real world.

The game has players wandering around their neighborhoods, their eyes torn between their phones and the real world, visiting places they never stopped at before and meeting people they might never have talked to before.  People are already talking up the game's health benefits.  The New York Timesreports that it "has kids on the move."  More importantly, when people are playing the game they are not sitting passively behind a screen in their house.

Pokémon Go is not, by itself, going to lead to dramatic improvements in the nation's health.  Nor was it intended to.  It is, however, yet another example about we can use games, or at least gamification, can help us with our health.

However promising gamification in health care may be, it is the AR that may well hold the most promise for health care.  Google was not wrong to pursueGoogle Glass, just premature.  Pokémon Go may be signaling that we're now finally ready for AR, and that it will be consumers as well as professionals who can benefit from it.

The potential uses in health care are virtually endless, but here are a few examples:

  • Ever been lost in a hospital, meandering haphazardly despite various signs and color-coded arrows?  How much better would an AR map be?  
  •  Ever feel like your doctor spends too much time staring at your chart or a screen?  Instead of looking there for information about you, how much better would it be if he/she was looking at you, with AR notations for key information about you?  
  •  Ever not understand what your doctor is telling you about your diagnosis or treatment?  It is well documented how few patients leave their doctors office/ER/hospital understanding what they were told.  How much better it would be if your phone could listen to the conversation, and provide AR "translations" into layman's terms of what is being said?  
  • Ever been told you needed a prescription, a test, or other treatment, and wondered how much it might cost?  You might have even asked your doctor, who most likely doesn't know either.  How much more powerful transparency efforts would be if those prices showed up as AR in the place of service at the time of the discussion about them, again with both the patient and the doctor seeing them?
  • Ever make "bad" food choices, despite calorie and nutritional information more omnipresent on labels and menus?  How much better would an interactive AR display of the information be?

Health care has no shortage of information.  Its problem is more making that information accessible to the right people, at the right time.  This is the real potential of AR, and figuring out how to do so in as impactful yet unobtrusive way will be the challenge for developers.

Pokémon Go is not the model for the future of health care, but it offers a model for it we should be paying attention to.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Cost of a data breach in health care reaches $355

By Claire Thayer, July 19, 2016

The Ponemon Institute released a few new reports this summer on the cost of data breaches as well as ability of companies to adequately mitigate online incidents and cyber attacks. While the reports cross all major industries, noted below are a couple of important highlights pertaining to healthcare.

In terms of analyzing external threats that arise outside the company’s traditional security perimeter, and use of online channels – email, social media, mobile apps, or domains, as primary attack vehicles, a July 2016 Ponemon Institute report finds that only 29 percent of respondents in health and pharma believe they indeed have the necessary tools and resources to mitigate external threats:

In addition to concerns on how best to mitigate external threats, the Ponemon Institute’s  2016 Cost of a Data Breach Study finds that the average global cost of a data breach per lost or stolen record reached $355 for healthcare, compared to $158 for all industries. 

The complete Ponemon Institute 2016 Global Cost of a Data Breach Study includes:

  • The average costs and consequences related to experiencing a data breach incident.
  • Seven global mega trends in the cost of data breach research.
  • The most common factors that influence and can limit the cost of a breach.

CMS Office of the Actuary on Health Expenditure Projections

By Clive Riddle, July 15, 2015

Where are US health care cost increases headed? The CMS Office of the Actuary tells us to expect 5.8 percent annual increases during 2015-2025, in their report: National Health Expenditure Projections 2015-2025.

The Office of the Actuary states “health spending is projected to grow 1.3 percentage points faster than Gross Domestic Product (GDP) per year over 2015-2025; as a result, the health share of GDP is expected to rise from 17.5 percent in 2014 to 20.1 percent by 2025. Federal, state and local governments are projected to finance 47 percent of national health spending (up from 45 percent in 2014).”

The report findings include:

  • National health spending growth is estimated to have been 5.5 percent in 2015.
  • By 2016, slower growth in health spending of 4.8 percent is projected as the enrollment in Medicaid and Marketplace plans slows and the associated declines in the number of the uninsured decreases.
  • Total annual health care spending growth is expected to average 5.8 percent over 2015-2025.
  • In 2015, medical price inflation slowed to 0.8 percent, down from 1.4 percent in 2014. Hospital prices increased by 0.9 percent while price growth in physician services fell by 1.1 percent.
  • The share of health expenses that Americans pay out-of-pocket is projected to decline from 10.9 percent in 2014 to 9.9 percent in 2025.
  • The insured share of the population is expected to continue to rise from 89 percent in 2014 to 92 percent by 2025.
  • Private health insurance expenditures are estimated to have increased by 5.1 percent from 2014 to 2015, reaching $1.0 trillion and will grow 5.4 percent thereafter to 2025.
  • Medicaid spending growth is slowing significantly in 2016, to 5.3 percent, which the report attributes to slower enrollment growth and stronger utilization management.
  • Medicaid spending growth is expected to average 5.6 percent for 2017-19, lower than in 2014-15.
  • In 2015, Medicare expenditures are expected to have been $647.3 billion, a 4.6-percent increase from 2014, driven partly by increased enrollment.
  • Medicare per-enrollee costs are estimated to have increased by only 2.4 percent, the same as the previous year, continuing the recent trend of low per-enrollee cost increases.
  • Prescription drug spending is projected to grow an average of 6.7 percent per year for 2016 through 2025. This follows growth of 12.2 percent in 2014 and 8.1 percent in 2015